Sparking INNOVATION

Instincts have a way of paving the path for innovation. Pediatric anesthesiologist Lisa Einhorn, MD, opened an email back in 2021 unaware that this was the moment that would propel her career trajectory steeply upward in the exciting realm of anesthesia research.

The email was from the then vice chair for innovation at Duke Anesthesiology, Evan Kharasch, MD, PhD, a world-renowned expert on pharmacology of anesthetics and pain drugs in perioperative medicine. He was looking for a potential pediatric anesthesia collaborator to explore a strategy that was never attempted before - the use of methadone, a long-acting opioid, for pediatric tonsillectomy surgeries that are typically outpatient procedures. Methadone, informs Associate Professor Einhorn, is an opioid often used intraoperatively for analgesia in inpatient pediatric surgeries, such as spinal fusions for scoliosis, pectus excavatum, and other major musculoskeletal surgeries in the US.

Not sure what she was agreeing to, Einhorn, who had done some work on opioids within the Duke system, instinctively said yes. The prospect of incorporating methadone into a broader pediatric surgical population was exciting. Kharasch and Einhorn met, discussed the unmet need and opportunity, found common interest, and decided to launch the collaboration.

Tonsillectomies are among the most common painful outpatient procedures performed in 500,000 to 750,000 children in the US every year. “There’s a long history of how post-tonsillectomy pain in children has been managed, particularly related to the use of opioids. And even after we’ve performed this surgery in millions of children over decades, we still haven’t quite figured out how to improve their analgesic experience after surgery,” says Einhorn.

Einhorn worked as a full-time clinician for six years prior to establishing a very successful research career built on a foundation of strong credentials. She completed her undergraduate degree from Emory University in 2007 and attended medical school at the University of Maryland School of Medicine. She then matched at Duke for her anesthesiology residency (2015) and followed that with a pediatric anesthesiology fellowship. Einhorn joined the anesthesiology department as an assistant professor in 2016.

“When our study is complete, we expect to have advanced the understanding of pediatric methadone pharmacology, improved analgesic outcomes in a population of children and adolescents with acute surgical pain, enabled reduced postoperative opioid prescribing, and achieved safer and more effective pediatric precision medicine.”

– Dr. Lisa Einhorn

She wrote her first ever grant during the summer of 2021 and successfully secured Duke Anesthesiology’s $30,000 DREAM Innovation Grant (DIG). Along with funds from the Fund to Retain Clinical Scientists (FRCS), awarded through the Dean’s Office of Physician Scientist Development, she conducted a pilot study on 60 pediatric tonsillectomy patients, 40 of whom received the long-acting methadone intraoperatively and 20 were given fentanyl as a control short-acting opioid. The results were encouraging. “We found that children who received methadone needed less opioids in the first week after surgery, a result which was not only statistically significant but also clinically meaningful.” Einhorn’s study, published in 2024 in the journal Anesthesiology, was the first ever to look at methadone for outpatient surgery in children.

Concurrently, Einhorn’s clinical mentor and Pain Medicine Specialist Padma Gulur, MD, recognized her research potential and asked her to apply for the department’s T-32 training grant that would allow her more non-clinical time to hone her research focus.

Einhorn has always tried to explore the “why” of doing things as opposed to accepting the status quo. Now, bitten by the research bug, Einhorn used her precious research time to apply for NIH funding through the NICHD R01 and R21 mechanisms with her initial study data and soon secured an R01 grant in 2024 to conduct a five-year fully-powered study on methadone in pediatric tonsillectomy patients.

“A cold query to Dr. Einhorn about a potential clinical study has led to an exciting collaboration. Her progress has been meteoric, she has already achieved status as an independent investigator, and her future prospects are bright and limitless. Her progress was so excellent that I suggested she bypass the usual route…she did, and not surprisingly, succeeded.” 

– Dr. Evan Kharasch, primary mentor

“We are also starting to study other populations now. We are about to begin a randomized trial in infants and young children undergoing cleft palate surgery, which is an entirely novel surgical population. Ultimately, methadone in pediatrics has been underutilized as an analgesic for surgery that historically people don’t consider to be ‘major’ or will cause significant post-operative pain. But we are expanding and studying methadone use in children because we recognize that all surgeries hurt, and we want to provide the best intraoperative analgesic.” Einhorn anticipates that with a single-dose long-acting methadone used intraoperatively, children will have improved pain control and need fewer opioids post-surgery.

As someone who thinks ‘out of the box’, Einhorn focuses on modalities that extend the effects of analgesia immediately after surgery and even beyond discharge, particularly as pain in children is hard to assess. “We know that surgical pain lasts beyond the PACU and lasts more than a day. Investigating new perioperative approaches, like methadone or regional anesthesia, that conceptually provide a longer duration of analgesia is what inspires me.”

Einhorn provides care for children at the Duke University Hospital operating rooms, the pediatric cardiac catheterization lab, the Eye Center, radiology, and endoscopy/bronchoscopy suite. As an attending on the Inpatient Pain Service, she manages inpatient care for adults and children. For many years, she was also the only pediatric general anesthesiologist providing care for children with complex congenital heart lesions for non-cardiac surgery.

Einhorn built her research on earlier work supported by the PDC Outcomes Research Team (PORT) award in 2020 to develop standardized post-operative prescribing protocols and minutely track opioid prescribing patterns in children after surgery. When she started digging, she found pediatric patients were prescribed excessive opioids not only in the number of prescriptions but also the number of doses per prescription. “I have been able to use my current work to help support reducing the need for opioids afterwards and to prolong the effects of analgesia safely.” To track both short- and long-term outcomes from a study standpoint, patients are followed up every day for a week after surgery, then after a month, three months and six months.

For Einhorn, her ‘aha’ moment to dedicate her life to pediatric pain management came in 2016. As a fellow, she was assigned to take care of a four-month-old baby, born prematurely, who had undergone three prior surgeries for gastroschises, a condition where bowels develop outside the body during fetal life and never return to the abdomen. Talking to the baby’s parents, Einhorn noted their anxious concern about post-operative pain. “With every surgery she had, the pain seemed to get worse,” they informed her.

After reviewing records of previous surgeries, Einhorn and her attending anesthesiologist made a call to insert an epidural, a procedure that can be risky in small babies. With parental consent, the epidural was placed before the surgery and used intraoperatively. To everyone’s delight, the baby was extubated after surgery and woke up with no sign of pain, looking around at everything, fully awake and so content, informs Einhorn, adding that the epidural stayed for four or five days and was completely transformative because the baby was comfortable after surgery. “This is when I realized that we had made a huge difference in the quality of care and postsurgical experience of the baby,” says Einhorn enthusiastically.

Einhorn has witnessed the unique complexities of managing pain in children and has always sought to improve the perioperative experience of patients. Mom to an autistic child, she particularly doubles down on her “passion project” to reduce sensory overload in a very stimulating hospital environment for what she calls a vulnerable population within a vulnerable population. “Everything we do in the operative environment is an assault on the senses. For children with autism and other neurodivergent conditions, this can be a miserable experience.”

On the Forefront of Innovation

Dr. Einhorn’s Pillars of Pediatric Pain Research

Revolutionizing Acute Postoperative Pain Management

• Dr. Einhorn is redefining pediatric pain care through the novel use of long-acting opioids, particularly methadone, in surgical settings where they’ve never been studied.
• Following her groundbreaking work in tonsillectomies, she is now launching a new trial exploring methadone use in cleft palate surgery, extending the potential of this low-cost, long-duration therapy to another underserved population.

Advancing Regional Anesthesia for High-Risk Pediatric Populations

• Through pioneering efforts at Duke, Dr. Einhorn is studying regional anesthesia techniques into pediatric cardiac surgery, a population historically underserved by this approach.
• Her PRACS trial, a first-of-its-kind randomized study comparing regional to local anesthesia in this group, earned national recognition and sets the stage for a planned multicenter expansion.

Predicting and Preventing Chronic Postsurgical Pain

• In an effort to identify which children are at risk for chronic postsurgical pain, Dr. Einhorn is developing biosignatures of pain vulnerability through a multifaceted approach: patient reported outcomes, functional MRI, biospecimen analysis, and quantitative sensory testing (QST).
• Building on an initial pilot study, she has now submitted an NIH R01 (with Dr. Katherine Martucci) to scale this work, laying the foundation for personalized, preventative pain care in major pediatric musculoskeletal surgery.

Consequently, Einhorn informs that Duke has implemented a six-question rapid screening assessment tool, developed at the University of Arkansas, that parents of every child, aged 2 to 17 years, must answer. This tool gives the anesthesia care team a score to plan their perioperative treatment pathways. According to the Organization for Autism Research (OAR), more than 110,000 autistic children have surgery every year in the US.

Einhorn has made it one of her goals to shed light on this population in the pediatric perioperative care space and develop guidelines that will give neurodivergent patients access to more comprehensive, safe and compassionate care across centers. “We are in the process of a culture change here and there is definitely more awareness and recognition that we need to be thoughtful about our approaches particularly to the neurodivergent population,” adds Einhorn, who is the principal investigator of a two-year, two-site OAR study called “The Impact of Adaptive Environments on the Perioperative Care for Children with ASD.”

To help her patients better, Einhorn feels her skills as a clinical researcher must be better too. Consequently, she enrolled for a Master of Health Science in Clinical Research through the Clinical Research Training Program in 2022, with an anticipated graduation date by 2026. With efforts both relentless and rewarding, Einhorn received the John Downs Research Award at the Society of Pediatric Anesthesiologists National Meeting in 2021 and her work on regional blocks for pediatric cardiac surgery was recognized with the Bosenberg Award for the best anesthesia abstract the subsequent year. In 2023, she was awarded the Society of Pediatric Anesthesia’s Young Investigator Grant for a randomized control trial evaluating novel regional anesthesia blocks in pediatric cardiac surgery patients.

Einhorn does not shy away from collaborations. Her concerted efforts extend beyond Duke to forge longstanding research partnerships with investigators at leading children’s hospitals around the world. These relationships keep her at the forefront of pediatric pain research and innovation. Not surprisingly, in 2020, she was the only anesthesiologist selected to co-lead the pain and behavioral health working group within the Department of Pediatrics Strategic Planning Committee that brought together a think tank of representatives for pediatrics, psychology, palliative care, surgery, etc., to develop a comprehensive vision and recommendations for the hospital leadership.

Along with neuroscientist Katherine Marcucci, PhD, she has submitted an R01 grant to prospectively collect data from adolescents to develop biosignatures using machine learning that can accurately predict chronic post-surgical pain. Pain biosignatures, she explains, are inputs, such as brain imaging before and after surgery, blood markers, sensory testing and patient-reported outcomes. “We will try to identify potential signatures that will help determine pain chronification or pain resilience post-surgery in individual
patients. Early identification of those at high-risk for persistent pain is critical to facilitating full functional recovery,” she informs.

Pioneering a New Standard

Duke’s First Pediatric Perioperative Pain Clinic

Dr. Einhorn is building the region’s first dedicated Pediatric Perioperative Pain Clinic, set to open in early 2026 at Duke’s Lenox Baker Children’s Hospital. This groundbreaking clinic will offer a comprehensive approach to surgical pain management for children and adolescents - before and after surgery.

Designed to fill a critical gap in care, the clinic will provide preoperative evaluations to identify and optimize patients at risk for difficult postoperative recoveries.

It will also serve as a crucial resource for managing persistent postsurgical pain, offering outpatient support that is currently unavailable elsewhere in the state.

With strong collaboration from Duke Anesthesiology and Duke Surgery, the clinic will offer an integrated model of care that prioritizes safe, effective, and individualized pain management.

As the first-of-its-kind in North Carolina, this clinic represents a transformative step toward redefining pediatric surgical recovery and elevating the standard of care across the region.

Being in the clinical realm not only informs Einhorn’s research in pediatric anesthesiology but also gives her insight into the gaps in the care for the children of North Carolina. She is spearheading efforts to establish an outpatient clinic dedicated to children with chronic pain, expanding access to specialized care beyond the hospital setting by removing silos in which care exists. “We have in-patient management nicely covered. Where we have gaps is in the outpatient world,” she informs. In the Fall of 2025, Einhorn began leading the launch of the region’s first Pediatric Perioperative Pain Clinic at Duke’s Lenox Baker Children’s Hospital to provide customized comprehensive pain management for children and adolescents before and after surgery. This innovative clinic is a collaborative partnership between Duke Anesthesiology and Duke Surgery and will offer preoperative evaluations for patients at risk of difficult recoveries and outpatient support for persistent postsurgical pain. As the first of its kind in North Carolina, it represents a major step forward in addressing a critical gap in the care of pediatric surgical patients across the region.

Chief of the Pediatric Anesthesiology Division, Edmund Jooste, MD, says, “This multidisciplinary, patient-centered approach is designed to prevent, assess, and treat pain in children undergoing surgical procedures. It will address not just physical pain, but also emotional, psychological, and social factors that can influence a child’s pain experience and recovery.”

As a pediatric anesthesiologist and as faculty on the Inpatient Pain Service, Einhorn has been able to see how the intraoperative experience can inform a patient’s post-operative experience. “What we do in the OR matters,” says Einhorn, reiterating the need to extend analgesia beyond the OR into the post-operative space to reduce reliance on opioids and therapies that could have negative side effects.

Einhorn lives in Durham with her husband, Jeremy and three children – Ari (10), Zoe (6) and Leo (4). A doting wife and mother, she is forging her path forward by working hard every day to look after her patients the same way she would like her children to be taken care of. This pediatric anesthesiologist’s goal is to enhance patient safety in a vulnerable population by infusing the most innovative pain management strategies with the highest dose of care. BP